Basic Information
| Provider Information | |||||||||
| NPI: | 1225255656 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KENNY | ||||||||
| FirstName: | TIFFANY | ||||||||
| MiddleName: | DAWN | ||||||||
| NamePrefix: | MISS | ||||||||
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| Credential: | OCCUPATIONAL THERAPI | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9097 E DESERT COVE AVE STE 110 | ||||||||
| Address2: | |||||||||
| City: | SCOTTSDALE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852606276 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4805514948 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 5281 N 99TH AVE STE 200 | ||||||||
| Address2: | |||||||||
| City: | GLENDALE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853053199 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6238890411 | ||||||||
| FaxNumber: | 6238890410 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/19/2007 | ||||||||
| LastUpdateDate: | 12/10/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/10/2019 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | 4635 | AZ | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
ID Information
| ID | Type | State | Issuer | Description | 326755 | 05 | AZ | MEDICAID |